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Utilization Management

KEPRO Utilization Management is the first line of defense to manage healthcare costs, while ensuring your members receive the right care, at the right time, in the right setting.

Healthcare Costs are Rising Rapidly.

How does this impact you and your members? 

  • Total health expenditures reached $2.6 trillion in 2010, ($8,402 per person) and 17.9% of US Gross Domestic Product (GDP)
  • Projections show that US health expenditures will account for 19.6% of US GDP by 2019
  • Hospital expenditures grew 4.9% in 2010, totaling $814 billion 

To counter this trend, you need powerful solutions that serve your members and your ROI. 

Your Members Get the Right Care, at the Right Time, in the Right Setting. 

KEPRO has 8 staff medical directors and a panel of more than 3,200 experienced peer reviewers available for review and consultation. Our expert clinicians apply nationally recognized guidelines and criteria to validate the medical necessity and level of care for services across the continuum. 

Our URAC accredited health utilization management program includes: 

  • Prior authorization of inpatient and outpatient services
  • Surgical procedures and transplants
  • Behavioral health services
  • Extended outpatient therapies
  • Radiology services
  • Durable medical equipment
  • Retrospective review
  • Prior authorization for organ/ tissue transplants and nursing services
  • Concurrent review
  • Discharge planning and care management program referral
  • Appeals (first and second level) 

KEPRO Thoroughly Assesses Necessity and Care Levels. 

We use recognized clinical criteria, plus eligibility and benefit plan design, to assess medical necessity and level of care. Our nurses channel members to network providers or negotiate out-of-network fees to secure the highest quality, most cost-effective services. We conduct concurrent reviews to determine if continued inpatient days or outpatient services are necessary. 

We Take a 360° Approach to Discharge Planning and Follow Up. 

Assessment for discharge planning, care coordination, and case management intervention is a standard part of our process and begins at the time we receive a prior authorization request. We coordinate with the facility discharge planning staff, the patient, and physicians throughout the hospitalization to ensure a timely discharge when the patient’s condition warrants it. If post discharge follow up is required, we refer the patient to our Case Management program for a seamless transfer of care coordination services. 

Proprietary Early Identification Helps Cut Costs. 

The most critical component of our program allows us to identify members who would benefit from more intensive care management services. Our process is driven by a set of proprietary analytic tools and statistical algorithms designed to identify the risk burden of your population. Using established triggers, we identify high cost and high risk members with multiple, complex co-morbidities. Then, we refer them to our (or another vendor’s) Case Management, Chronic Care Management, Specialty Case Management (oncology), or Maternity Management programs. 

KEPRO Provides Proven Results for Your Members and Your ROI. 

We measure program success based on financial and clinical outcomes. 

Our standard measurements include: 

  • Average length of stay
  • Bed days per 1,000 covered lives
  • Admissions per 1,000 covered lives
  • Savings and ROI  

Our clinical reports also show your top 25 diagnoses for acute and outpatient costs associated with these services, as well as denial and appeal volumes. We provide trends over time, which can help you design a more effective benefits plan and have more satisfied participants.

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Please describe KEPRO data security that ensures member information is protected.

As an organization that is charged with storing and transferring Protected Health Information (PHI), KEPRO is bound by HIPAA regulations, and is accustomed to managing the security and privacy of PHI. KEPRO currently exchanges data successfully and confidentially via secure encrypted means in support of all of our federal, state, and local government programs, and with commercial clients.

KEPRO has been implementing and supporting systems that require medical record, data security, and transmission for more than a quarter of a century, and has always placed primary importance on using systems that allow for fast and efficient connectivity, while still providing the highest level of data and system security. Our proven internal and external policies and protocols ensure compliance with state and federal laws and regulations, as well as any additional security measures you may require.

We have a stringent KEPRO Comprehensive Confidentiality Plan that governs our processes. KEPRO’s Privacy Officer, Security Officer, and the Compliance Officer have ultimate responsibility for oversight of the processes and procedures contained in the KEPRO Comprehensive Confidentiality Plan.

KEPRO's system is secure. Our information systems are secured by an in-depth strategy that utilizes multiple layers of operational, management, and technical controls to protect KEPRO assets. We also employ software programs designed to prevent unauthorized use by staff or outside entities.

All KEPRO information systems employ common security controls such as Firewalls, Anti-virus, Role Based Access, FIPS 140-2 Encryption for mobile devices, and the requirement of strong passwords. Information system users are assigned a security role based upon access requirements relevant to their positions and information/program privileges.

The HIPAA Security Rule requires entities to implement information systems that control access to healthcare and related systems. KEPRO adopts a subset of NIST 800-53 Rev 3 Security controls to maintain compliance with HIPAA. Based on these security standards, KEPRO mitigates risk to its Information system by focusing on such controls as:

  • Log-In Security. HIPAA security requires the use of secure User IDs and the use of passwords. KEPRO requires multiple account authentication processes within its information systems to verify the identities of our end-users. KEPRO's policy requires strong passwords that are changed frequently.
  • Access Control. HIPAA requires one of the following: Context Based Access, Role Based Access, or User Based Access. User Based Access is part of the Log-In Security component. KEPRO's Role Based Access gives individual users access relevant to their function in the organization.
  • Audit Trail. HIPAA requires the use of an audit trail to identify who accesses PHI. KEPRO systems track those who change the patient record, the date and time the record was modified, and the specific information changed. The system includes a read only audit trail that captures each time a system user views a case.
  • Session Time-out. KEPRO information systems account for session inactivity by locking screens after 10 minutes of inactivity.
  • KEPRO's physical space is secure. KEPRO’s computer, telephone, and hardware systems are located in climate controlled rooms with fire-suppression and electronic locking system. We allow only authorized access to the room.
  • KEPRO focuses training on confidentiality and security issues. All KEPRO employees undergo rigorous training on security and confidentiality of PHI. We have successfully provided this training to all staff regardless of their respective roles/duties.

KEPRO Headquarters

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777 East Park Drive, Harrisburg, PA 17111
Toll-free: 800.222.0771
Phone: 717.564.8288
Fax: 717.564.3862